Healthcare Provider Details

I. General information

NPI: 1609368182
Provider Name (Legal Business Name): BORIS TREGUBOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date: 02/13/2019
Reactivation Date: 04/20/2019

III. Provider practice location address

8900 VAN WYCK EXPY
RICHMOND HILL NY
11418-2897
US

IV. Provider business mailing address

8900 VAN WYCK EXPY
RICHMOND HILL NY
11418-2897
US

V. Phone/Fax

Practice location:
  • Phone: 718-206-6000
  • Fax:
Mailing address:
  • Phone: 718-206-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number313588
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: